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General NPI Number Information
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NPI Number | 1912075250
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Entity Type | Organization
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Legal Business Name | CHAMPLAIN VALLEY GASTROENTERLOGY PC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 03/12/2015
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Provider Practice Location Address
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Address Line | 164 BOYNTON AVENUE SUITE 5
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City | PLATTSBURGH
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State | NY
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Zip | 12901
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Country | US
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Telephone | 518-324-7920
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Fax | 518-324-7922
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Provider Business Mailing Address
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Address Line | 164 BOYNTON AVENUE SUITE 5
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City | PLATTSBURGH
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State | NY
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Zip | 12901
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Country | US
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Telephone | 518-324-7920
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Fax | 518-324-7922
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY GRETZ
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Credential | MD
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Telephone | 518-324-7920
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 220526
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License Number State | NY
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